The MRI Report

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Today was the first day of Organized Team Activities (OTAs) for the NFL. On the first day, two anterior cruciate ligament ( ACL) tears were reported. One Sean Lee, linebacker from Dallas Cowboys, and Domenik Hixon, wide receiver of the Chicago Bears both tore their ACL’s. Domenik Hixon’s debut season with the Chicago Bears was over on day one. He tore his ACL for the third time today. The first injury was in 2010 then in 2011. This last injury will most likely bring an end to his career after six seasons and eight years in the league. He signed with the Bears in March after one season with the Carolina Panthers. He spent most of his career with the New York Giants, having won two super bowl rings with them. The anterior cruciate ligament (ACL) is one of the main stabilizing ligaments in the knee, and it is the most commonly torn ligament in the knee. It prevents the thighbone (femur) from moving forward on the shinbone (tibia). It may be torn by pivoting and twisting the knee, or by hyperextension. Landing awkwardly from a jump may also result in a torn ACL. Symptoms include hearing or feeling a pop in the knee, swelling in the knee, pain, and a feeling of instability, especially with side to side movement. The knee may “give way” or “buckle” with weight-bearing. An athlete in a sport which requires pivoting, cutting, or jumping requires surgical reconstruction to prevent recurrent episodes of instability and further knee damage such as meniscus tears and cartilage damage. The surgery involves reconstructing a new ACL from either the athlete’s own tissue or donor tissue from a cadaver. The rehabilitation process after surgery takes several months, and return to play depends on the type of surgery and the sport, however on average the recovery time is 7 to 10 months. Hixon’s situation is more serious due to the fact that this is his third ACL rupture. Unless there is a convincing reason why his ACL reconstructions keep failing, and he develops some amazing degree of confidence on his knee after a second repeat surgery, it would be a super awesome feat for him to ever make it back into an NFL uniform.

Primus Sports Medicine Staff- OB

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We have recently learned about another lawsuit brewing up in the N.F.L. Many former NFL players are filing a claim that prescription pain killers were misused during their career. In some cases, this misuse lead to misdiagnoses, and in other cases covered up symptoms from significant injuries. What has been talked about the most are neck injuries in which players have actually played on presumed vertebral fractures because their pain were covered up by pain medications. After their playing days were over, they were to find out by outside surgeons how serious and devastating their injuries actually were, and in some instances could have lead to death or permanent paralysis.

Prescription pain medications can come in the form of pills or liquid that you can take by mouth, or injections that can be given directly through muscle or I.V. These are medications that can not be purchased over the counter, but can only be given through a doctor’s prescription. Often times, if a player is limited by their ability to compete due to pain from an injury, pain medications may have been given to allow that athlete to play.

Former Bears quarterback Jim McMahon developed a 100 pill-a-month dependency on Percocet

As a former N.F.L. player myself and current orthopedic surgeon that prescribes these medications on a regular basis, you have to very careful about understanding the treatment for pain from bruises that will not get worse or do long term damage, versus treating pain from significant injuries that can definitely get worse if not adequately protected. In the professional athletic arena, our society for many years accepted the fact that rules that apply to the athletes may not apply to the general population. In a normal doctor-patient relationship, any prescription pain medication is given with a clear explanation of risks, and usually along with adequate protection for the condition that is causing the pain. In the professional athletic arena, the question being asked now is whether these athletes have been given the same pain medications but without the understanding of the risks of the medications and of playing, with the top priority of simply covering the pain to allow the athletes to compete.

It took public awareness about the risks of concussions to finally lead to change in how we think about these injuries, maybe the same will be for the use of prescription pain medications. As the public becomes more aware and conscious of what it takes sometimes for these athletes to continue to play at the high level they do, our societal acceptance may also change as we look at these retired athletes that are now paying the price…

Stay tuned as this litigation proceeds, as we will bring you insights from a formal N.F.L. player turned surgeon!

Primus Sports Medicine Staff- OB

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Gerald Henderson of the Charlotte Hornets underwent arthroscopic surgery on his right wrist to remove scar tissue. He will have his wrist immobilized for about two weeks and will begin rehabilitation following.

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After suffering a blow to the back of the head from Dwayne Wade’s knee Tuesday night, Pacers’ forward Paul George has been diagnosed with a concussion today. Although he did not demonstrate symptoms of a concussion to his athletic training and medical staff, he mentioned to reports that he briefly blacked out and had blurred vision, two common signs of a concussion, for the remainder of the game. After these reports, George was taken to a neurologist for further treatment.

Before George can play in Game 3 of the series in Miami on Saturday, he must satisfy all of the protocols set forth by the NBA’s concussion policy (see below). He cannot return to play until he is symptom-free at rest and has passed a step-by-step protocol of gradually increased exertion. Paul George has just 3 days to satisfy these requirements.

NBA Concussion Policy:

“Return-to Participation Decisions:

Once a player is diagnosed with a concussion he is then held out of all activity until he is symptom-free at rest and until he has no appreciable difference from his baseline neurological exam and his baseline score on the computerized cognitive assessment test.

The concussed player may not return to participation until he is asymptomatic at rest and has successfully completed the NBA concussion return-to-participation exertion protocol.

Return-to Participation Protocol:

The return to participation protocol involves several steps of increasing exertion — from a stationary bike, to jogging, to agility work, to non-contact team drills.

With each step, a player must be symptom free to move to the next step. If a player is not symptom free after a step, he stops until he is symptom free and begins again at the previous step of the protocol (i.e., the last step he passed without any symptoms).

While the final return-to participation decision is to be made by the player’s team physician, the team physician must discuss the return-to-participation process and decision with Dr. Jeffrey Kutcher, the Director of the NBA’s Concussion Program, prior to the player being cleared for full participation in NBA Basketball.

It’s important to note that there is no timeframe to complete the protocol. Each injury and player is different and recovery time can vary in each case.”

A concussion is a type of traumatic brain injury, or TBI, caused by a bump, blow, or jolt to the head (coup injury) that can change the way your brain normally works. Concussions can also occur from a fall or a blow to the body that causes the head and brain to move quickly back and forth (countracoup).

Symptoms of a concussion fit into four main categories:

Thinking and remembering

Not thinking clearly

Feeling slowed down

Not being able to concentrate

Not being able to remember new information

Physical

Headache

Fuzzy or blurry vision

Nausea and vomiting

Dizziness

Sensitivity to light or noise

Balance problems

Feeling tired or having no energy

Emotional and mood

Easily upset or angered

Sad

Nervous or anxious

More emotional

Sleep

Sleeping more than usual

Sleeping less than usual

Having a hard time falling asleep

Paul George demonstrated some physical symptoms during the game on Tuesday, however, he did not share this information with the Pacers’ medical staff. Hopefully, George is not experiencing any new or worsening symptoms.

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Chicago White Sox rookie, Jose Abreu, had an MRI to determine if there were any damages to his left ankle. The MRI revealed “inflammation only” according to sources. His official diagnosis is “Posterior Tibial Tendonitis.” Abreu has been placed on 15-day DL.

Posterior tibial tendonitis is one of the most common problems of the foot and ankle. It occurs when the posterior tibial tendon becomes inflamed or torn. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in a flatfoot.

The posterior tibial tendon is one of the most important tendons of the leg. A tendon attaches muscles to bones, and the posterior tibial tendon attaches the calf muscle to the bones on the inside of the foot. The main function of the tendon is to hold up the arch and support the foot when walking. Once the tendon becomes inflamed or torn, the arch will slowly fall (collapse) over time.

Symptoms include:

Pain along the inside of the foot and ankle, where the tendon lies. This may or may not be associated with swelling in the area.

Pain that is worse with activity. High-intensity or high-impact activities, such as running, can be very difficult. Some patients can have trouble walking or standing for a long time.

Pain on the outside of the ankle. When the foot collapses, the heel bone may shift to a new position outwards. This can put pressure on the outside ankle bone. The same type of pain is found in arthritis in the back of the foot.

Test for this injury include:

Too many toes” sign. When looking at the heel from the back, normally only the fifth toe and half of the fourth toe are seen. In a flatfoot deformity, such as one that can occur with this injury, more of the little toe can be seen.

“Single limb heel rise” test. Being able to stand on one leg and rise up on “tiptoes” requires a healthy posterior tibial tendon. When a patient cannot stand on one leg and raise the heel, it suggests a problem with the posterior tibial tendon.

Treatment for posterior tibial tendonitis is typically non-surgical, and includes, but is not limited, the following:

Decreasing or even stopping activities that worsen the pain as soon as possible. Switching to low-impact exercise is helpful. Biking, elliptical machines, or swimming do not put a large impact load on the foot, and are generally tolerated by most patients.

Apply cold packs on the most painful area of the posterior tibial tendon for 20 minutes at a time, 3 or 4 times a day to keep down swelling. Placing ice over the tendon immediately after completing an exercise helps to decrease the inflammation around the tendon.

Drugs, such as ibuprofen or naproxen, reduce pain and inflammation.

A short leg cast or walking boot may be used for 6 to 8 weeks. This allows the tendon to rest and the swelling to go down.

Most people can be helped with orthotics and braces. An orthotic is a shoe insert. It is the most common nonsurgical treatment for a flatfoot. An over-the-counter orthotic may be enough for patients with a mild change in the shape of the foot. A custom orthotic is required in patients who have moderate to severe changes in the shape of the foot.

A lace-up ankle brace may help mild to moderate flatfoot. The brace would support the joints of the back of the foot and take tension off of the tendon.

Physical therapy that strengthens the tendon can help patients with mild to moderate disease of the posterior tibial tendon.

Cortisone is a very powerful anti-inflammatory medicine that your doctor may consider injecting around the tendon. A cortisone injection into the posterior tibial tendon is not normally done. It carries a risk of tendon rupture.